LIBRARY OF CONGRESS 



021 623 840 ^ 



HoUinger Corp. 
pH 8.5 



RC 155 
.N82 
Copy 1 



HEMORRHAGIC 



Malaeial Fevee, 



DELIVERED BEFORE THE MEDICAL SOCIETY OF NORTH CAR- 
OLINA, AT ITS 21sf ANNUAL MEETING, HELD 
IN CHARLOTTE IN MAY, 1874, • 



BY 



WM. A, B. ^nTORCOM, M, D.. 



OF EDENTON, 



PRESIDENT OF THE SOCIETY. 



PUBLISHED BY REQUEST OF THE SOCIETY, 



RALEIGH, N. C. : 

Edwards, Broughton & Co., Book'& Job Printers and Book Binders, 

August, 1874. 



\ 



HEMORRHAGIC 

Malaeial Fevee, 



DELIVERED BEFORE THE MEDICAL SOCIETY OF NORTH CAR- 
OLINA, AT ITS 21sT ANNUAL MEETING, HELD 
IN CHARLOTTE IN MAY, 1874, 



BY 

WM. A. B. ISrORCOM, M. D., 

OF EDENTON, 

PRESIDENT OF THE SOCIETY. 



PUBLISHED BY REQUEST OF THE SOCIETI. 



RALEIGH, N. C. : 

Edwards, Broughton & Co., Book & Job Printers and Book Binders, 

August, 1874. 



IH EXCHANGB 

jl. B.St. El by- 



H.EMORRHAGIC MALARIAL FEVER. 



BY WM. A. B. NORCOM, M. D., EDENTON, N. C. 



Gentlemen : I thank you for the honor done me. It is 
customary for the presiding officer of a State Medical So- 
ciety to write an address upon some subject of general in- 
terest to the profession, and not strictly medical. From 
this 1 shall depart, having chosen for mine Htemorrhagic 
Malarial Fever. I do this because, since our late war, it has 
been very prevalent in the Southern States, is a disease of 
great gravity, and a high mortality has generally atten- 
ded its treatment ; and because I am not aware that 
a physician in this State has contributed a paper upon this 
subject. It has received from different authors quite a 
number of names. In addition to the foregoing it is called 
Cachsemia, Yellow Remittent, Icterode Pernicious Fever, 
Malignant Congestive Fever, Up-country Yellow Fever, 
New Disease, Black Jaundice, Malarial Hsematuria, &c. 
The name I have selected, much the best, was given it, I 
think, by Dr. R. F. Michel, of Montgomery, Alabama, in a 
paper contributed by him, in March, 1869, on this disease to 
the Alabama Medical Association, and which was published 
by request of the Society, in July following, in the New Or- 
leans Journal of Medicine. Dr. Michel gives the s.ymptom- 
atology of this disease in an admirably graphic style, but 
his treatment is justly open to adverse criticism. Many 
authors. Dr. Michel among them, contend that it is a new 
disease, nowhere to be seen except in our Southern States, 
and that it first appeared in 1867. That this is a very 



2 



HJEMORRHAGIC MALARIAL FEVER. 



great mistake is demonstrable by a catena of irresistible ev- 
idence. I am not aware that it was treated of in a mono- 
graph devoted especially to it, but it is often referred to by 
authors in connectio^"^ with their descriptions of Malarial 
Fevers, of which it is but a severe form. Without bringing 
to the witness-stand any other author, I am sure the follow- 
ing references to his admirable papers on Malarial Fevers, 
in Vol. I, of Reynolds's System of Medicine, clearly show 
that Dr. Maclean was well acquainted with this as well as a 
much severer form of Malarial Fever. Says he : "of all the 
symptoms nausea and vomiting are the most constant and 
the most exhausting; the vomited matters at first consist 
of any food that may be in the stomach, then of a watery 
fluid, often in surprising quantity. Soon bilious regurgita^ 
tion takes place, and the rejected matters become of a green- 
ish yellow color, then brown, and finally, in extreme cases, 
black, resembling the 'black vomit' of yellow fever. The 
resemblance will be more striking if, as sometimes happens, 
the skin assumes a yellow tinge and a hemorrhagic tendency 
be evinced. I have seen two cases at Madras, both in officers 
of the Forest Conservancy Department, in which tlie liaDm- 
orrhagic range was most extensive, the patients passing 
blood/m»^ the stomach, howels and kidneys " 

Now who can doubt that Dr. Maclean was long ago fami- 
liar with this disease? Dr. Capehart, of Edenton, had a 
case in 1866. My first case was in 1867, and Drs. AVinborne 
and Dillard, of Chowan county, inform me that they saw a 
case fifteen years ago. Dr. Maclean further says : "I have 
notes of three other cases ; in all the urifie was lloodijy He 
ttien goes on to say : "The older authors describe, and ver}' 
graphic some of their descriptions are, what they called 
putrid Remittents." These, he says, occurred in soldiers 
landed on the shores of Bengal, who had scurvy from pro 
tracted sea voyages, "and the mortality was shocking." 
"An entire regiment, 900 strong, was almost destroyed by 
malarial fevers and bowel complaints in a few weeks, and 



HEMORRHAGIC MALARIAL FEVER. 



3 



those of us who survive can bear testimony to the truthful- 
ness of the description of 'putrid' remittent fevers given by 
the writers above alluded to.'' The same author further 
says: " without, however, any scorbutic taint, we may have 
remittent fever presenting, from the commencement, an ady- 
namic character. I was very familiar with cases of this 
kind when serving in the immediate vicinity of Hyderabad 
in the Deccan." He describes the skin in these as yellow 
and covered with petechise, the pulse exceeding 120, and a 
disposition to hcemorrhage f rom nose, mouth and howels. I'm 
sure you'll not require of me additional proof, though I 
could give it, to show, not only that this is not a new dis- 
ease and peculiar to our Southern States, but that it, as well 
as a much more malignant form of malarial fever, was 
known prior to 1867. 

Definition. — A malignant malarial fever, the result of 
frequent attacks of intermittent, or of a prol')nged and ex- 
hausting remittent, characterized by ha^maturia, hfematem- 
esis, epistaxis, enterorrhagia, metrorrhagia or haemorrhage 
from the gums and fauces, or from two or three of these at 
the same time ; most distressing and incessant nausea and 
vomiting, and complete jaundiced condition (greenish-yel- 
low hue) of body. The cold stage, though not always, is 
generally w^ell marked, and the paroxysms oftenest recur 
about every ten or twelve hours, but far more frequently 
the fever is uninterrupted by intermission or remission. 

My definition is somewhat similar to that given by Dr. 
Michel, but broader and more comprehensive. He only men- 
tioned one form of haemorrhage — the hsematuria. A very 
great objection to calling this disease Malarial Hematuria 
is that it takes in only one source from which the hsemor- 
rhage is derived. 

Pathological Anatomy. — Having never made a post 
mortem of a patient who died of this disease, I must avail 
myself of the labors of others ; and shall draw chiefly from 
the writings of Prof. Jos. Jones, of the University of La., Dr. 



HJEMOBBHAGIG MALARIAL FEVER. 



Michel, of Montgomery, Ala., and from Prof. Maclean's ar- 
ticles on malarial fevers in Vol. I, of Reynolds's System of 
Medicine. It is much to be regretted that throughout our 
whole country, especially in the smaller towns, the horror 
which pervades the popular mind at the bare thought even 
of dissecting the dead, should so seriously limit scientific 
investigation. The physician is thus often deprived of the 
possession of that knowledge which might save many lives. 

The morbid anatomy of this disease does not differ essen- 
tially from that of other forms of malarial fever, only in de- 
gree. 

The general appearance of the bodies of those who die 
from this disease often shows great emaciation, though not 
always; the skin is of a greenish-yellow hue and sometimes 
mottled. 

Notwithstanding the nervous system ordinarily shows 
no decided post mortem lesions, the symptoms during life 
show that it is profoundly impressed by malaria. As a gen- 
eral rule, the cerebro-spinal and sympathetic nervous sys- 
tems present no marked lesions. (Jones.) Dr. Michel men- 
tions none. Dependent portions of lungs congested with 
blood ; in every other respect normal. (Jones and Michel.) 

By inducing sudden congestions, by its depressing effects 
upon the heart, and general and capillary circulation, and 
by its powerful action both on the sympathetic and cerebro- 
spinal systems of nerves, malaria tends to cause formation 
of heart-clots, although there is an actual diminution of 
fibrin in the blood. (Jones.) The fibrinous element ma}^ 
be deposited in the heart and blood vessels during life, and 
not only give rise to distinct phenomena, but cause death 
in cases which would otherwise have terminated favorably. 
(Jones.) The heart itself presents a healthy appearance. 
(Michel and Jones.) The mucous membrane of stomach is 
softened, ecchymosed and discolored with bile. The blood 
vessels of stomach are injected and mottled, and of a pur- 
plish hue, which appears to indicate, not inflamation, but 



HEMORRHAGIC MALARIAL FEVER. 



5 



strangnation and accumulation of blood in the capillaries. 
(Jones). The distressing vomiting appears to depend upon 
the contact of altered bile and the irritation of the ner- 
vous centres which supply the stomach with nervous 
force, by the altered blood and by the malarial poison. 
(Jones.) The mucous membrane of the small intestines is 
frequently of a purplish, irregularly injected, mottled ap- 
pearance, especially after the administration of purgatives. 
(Jones.) The liver is of a slate and bronze hue, often soften- 
ed, and increased in weight somewhat, which latter is caused 
partly by the stagnation and accumulation of blood in its 
capillaries and blood vessels, and the deposit of pigment 
matter in its structures. (Jones.) In one case Dr. Michel 
describes the liver as "firm and solid, and of a dark choco- 
late color." The spleen is much enlarged, softened and filled 
with disorganized colored corpuscles, and on the exterior of a 
dark slate color. (Jones and Maclean.) Dr. Michel describes 
the spleen as having "a firm and solid consistence." The 
gall bladder is distended with thick greenish-black bile. 
One thousand gr. Sp. Gr. 1036 have been found in it. (Jones.) 
In thin layers it presents a deep green and yellow color. 
Dr. Michel lays great stress on this condition of the gall 
bladder, but it is realh^ nothing more than an aggravated 
condition of what exists in all forms of malarial fever. The 
kidneys are much increased in size and weight (Jones and 
Michel) being much congested. The haemorrhage from the 
kidneys is preceded by congestion of these organs, and is 
attended with desquamation of the excretory cells and tu- 
buli uriniferi. (Jones.) Slate-colored spots sometimes ap- 
pear upon the kidneys. (Jones.) Supra-renal capsules and 
bladder in normal condition. What I have said concern- 
ing the post-mortem lesions found in the kidneys, applies 
only to Malarial Haematuria. In the other forms of Hsem- 
orrhagic Malarial Fever the kidneys do not materially dif- 
fer from the conditions observed after death in severe re- 
mittents. 



6' 



HyEMORRHAGIC MALARIAL FEVER. 



The two roost important points to note in regard to the 
blood in this disease is a great diminution of the fibrin and 
colored corpuscles. The latter suffer more from the mala- 
rial poison than any constituent of the blood, their rapid 
destruction loading it with black pigment, as has been 
clearl}' shown by Frerichs and J. F. Meigs. This pigment 
is not found in the kidneys, nor does it accompany their 
diseases. These facts have an important bearing on the 
treatment. 

The mechanism of the haemorrhage in Malarial Hsema- 
turia is still a quaestio vexata, some contending that it is a 
true haemorrhage, while others think it due to elimination, 
the debris of the blood being removed by the depurating 
action of the kidney. I am inclined to think both these 
views correct. Prof. Jones ( who thinks it a true haemor- 
rhage) says the pigmentary matters in the urine in the 
milder forms of malarial fever (non-haemorhagic) are de- 
rived chiefly from the broken down colored corpuscles, and 
that from a careful consideration of the symptoms and sub- 
sequent post mortem revelations, we are led to the belief 
that the pigment comes mainly from the blood cells, and 
that its amount may be taken as an index or measure of 
their destruction. Taking this view, which is undoubtedl}' 
correct, w^e do not find blood in the urine in the milder 
forms of malarial fever, but its debris is actuall}^ removed 
by the depurating action of the kidney. This is, perhaps 
often the case in the mild forms of Malarial Hsematuria, 
but not in the severe cases. In two very admirable papers, 
among the best I have seen on this subject, contributed to the 
Richmond and Louisville Medical Journal, by Drs. Hudson 
and Mabry, of Alabama, this view is taken of the mechan- 
ism of the hgematuria in the worst as well as the mildest 
cases. Undoubtedly it is desirable for the debris of the 
blood to be removed, if this could occur without an alarm- 
ing haemorrhage ; for those extremely important little anat- 
omical elements of the blood, and oxygen-carriers, the red 



H^MORRHAOIG MALARIAL FEVER. 



7 



globules, when dead, cannot be revivified ; and their re- 
moval, with the provision specified, would be most salutary. 
In the worst forms of Malarial Haematuria, as well as when 
the blood proceeds from the stomach, nose, &c., a true 
haemorrhage, I think, from ruptured capillaries occurs, for 
the blood will clot in the vessel that receives it. I wish I 
could, from personal observation of the post-mortem lesions 
in this disease, acquit myself more crcviitably under this 
branch of the subject ; but being unable to do so, I will pass 
at once to the 

Clinical History. — The attack is usually, though not 
always, ushered in by a well pronounced chill, which lasts 
from half an hour to two hours, accompanied by intense in- 
ternal burning heat, the patient craving ice and cold drinks, 
and at the same time importuning to be warmly covered, 
asking for hot bricks to the feet, &c. Exceptionally, in 
very rare cases no chill occurs, and in Malarial Hematuria, 
we sometimes have nothing more than slight shivering 
sensations, which occur just prior to the passage of the 
bloody urine, which is accompanied with quite intense pain 
over the region of the kidneys. Synchronous with the chill, 
or a little later, most distressing nausea and vomiting oc- 
cur, the matters ejected being first whatever food may be 
in the stomach, and afterwards biliary matter of a thick 
ropy character, and of various colors — yellow, dark brown, 
green, and says Dr. Jones, in extreme cases, hlaclc vomit. 
Indeed in some cases profuse haematemesis occurs, which, 
far oftener than otherwise, proves rapidly fatal. I know of 
several such cases which occurred in the practice of some of 
my professional brethren, which soon terminated fatally. I 
am inclined to think this one of the most fatal forms of the 
disease except that attended with ursemic intoxication. 

When Dr. Michel wrote his paper he could not have seen 
or heard of this form of the disease, for he says, "we have 
no blood, no trace of a haemorrhage from the stomach." The 
distressing nausea and vomiting (though the matters vom- 



8 



H^EMOBBHAGIC MALABIAL FEVER. 



ited are) is not peculiar, as some assert, to this disease, as in 
simple intermittents and remittents it is sometimes equally 
as tormenting. The nausea sometimes continues a week 
after convalescence is established. Along with these symp- 
toms, and which continue until death or convalescence, 
comes an almost unbearable restlessness and jactitation. 
Sleep, unless produced by hypnotics, is impossible, and the 
patient constantly tosses about on the bed exhausting him- 
self in fruitless efforts to seek comfort and repose. After the 
nausea and vomiting have continued a few hours, we have 
jaundice, the whole body rapidly assuming a bronzed yel- 
low" hue, caused by clogging up of the biliar}" ducts with 
bile and consequent absorption of biliverdin, which discolors 
almost all the tissues of the body. 

The fever, which immediately succeeds the chill, is not 
often very marked and high, the pulse in adults rarely 
reaching 100 per minute, except after an exhausting haemor- 
rhage, when it goes up to 150 and is extremely feeble. 
Sometimes, especially in the epistaxic form, it goes up soon 
after the chill to 120. The temperature ranges from normal 
to 105°. Just prior to death, after a large haemorrhage, it 
may go down to 96° or a little less. The thirst is very great 
and almost uncontrollable. The patient seems to crave 
nothing but ice cold drinks. The skin is usually not very 
hot, the face wears an anxious aspect and the eyes appear 
sunken. Headache occurs sometimes, but is usually not an 
annoying symptom. Hiccough rarely occurs, but when it 
does is very troublesome to the patient. In from one to three 
hours after the chill, exceptionally sooner, a bloody discharge 
occurs from kidneys, nose, bowels, stomach, womb, gums, 
or fauces, or from two or more combined. I have known a 
haemorrhage to usher in an attack. The hEemorrhage oc- 
curs oftenest from the kidneys, next from the nose, and rarely 
from the other sources, very rarely from the gums, fauces and 
womb. Theurinein Malarial Ha?maturia merits careful study 
When the haemorrhage does not proceed from the kidneys 



HEMORRHAGIC MALARIAL FEVER. 



9 



the urine does not materially differ from its condition in re- 
mittent fever. Its color varies from amber to black, accord- 
ing to the extent of destruction of tlie colored corpuscles, 
and sometimes in addition to the debris, much blood is 
passed from rupture of small vessels. It has an acid reac- 
tion, and the sp. gr. varies generally from 1010 to 1020 or 
over. The quantity passed (sometimes with pain about the 
neck of the bladder) is either normal (rarely below) or very 
much increased. In Uraemia, however, the function of the 
kidneys is almost, if not wholly, suppressed. Albumen is 
frequently found in the urine, but Dr. Jones says never ivith- 
out structural alteration of the kidneys, most probably due to 
the prolonged action of the malarial poison ; and that this 
element in the urine is not to be referred to the watery con- 
dition of the blood caused by the destruction of the colored 
corpuscles, and diminution of the albumen and fibrin. The 
presence of albumen in the urine in this form of the disease 
IS attended also, according to Dr. Jones, with the presence of 
colored blood corpuscles, excretory cells of the kidneys and 
the tubuli uriniferi, impacted often with altered blood cor 
puscles. He farther says, he has even detected the malpig- 
hian corpuscles containing altered blood corpuscles, and 
deepl}^ stained by the coloring matter of the blood. In the 
form of the disease, too, we are now considering, the func- 
tion of the kidneys is so impaired that neither the urea nor 
the mineral acids are increased in the urine. They thus 
often accumulate in the blood, poisoning it, and also pro- 
ducing marked and alarming disturbance of the nervous 
system. 

In very extreme cases, where the vitality is very low, 
vibices and purpura hsemorragica appear on the surface. 

I will now mention a symptom, blindness, which I never 
saw but once, and have never seen described in any paper I 
have seen on this disease. It occured in Col. Garrett, of 
Edenton, a patient of Dr. T. J. Wdght, whom I saw in con- 
sultation with him. Total blindness occurred, and mry 
2 



10 



H^mrORRHAGIC MALARIAL FEVER. 



suddenly. Dr. Wright thought that, owing to the general 
haemorrhagic tendency (Col. G. had Malarial Hfematuria i. 
and the suddenly developed blindness, the latter was caused 
by rupture of small retinal vessels. He wrote a descri})- 
tion of the case, and sent it to Dr. Drinkard, of Washington 
City, a skilled and reliable Ophthalmologist, whose views 
coincided with Dr. Wright's. We both regretted very much 
his eyes were not examined with the ophthalmoscope. This 
case occurred in November. 1873. The patient's vision, as 
soon as he began to convalesce, rapidly improved, but is not 
yet normal. I once inclined strongly to the belief that this 
blindness was due to cinchonism, as we were compelled to 
give him a great deal of quinine : but the great rarity of 
blindness from this cause, and the plausibility of Dr. 
Wright's view, supported by Dr. Drinkard, caused me to lose 
confidence in mine. This was one of the worst cases I ever saw 
recover, and the patient owes his life to Dr. Wright's unre- 
mitting care and attention. Col. G. can see well enough to 
walk about alone, but not to read well except large print. 

The sighing respiration, which is a prominent symptom 
in this disease, seems to be due to great debility, and the 
extensive destruction of the red globules. 

The coating of the tongue does not vary much. It 
is usually of a yellowish-brown color. Ihe bowels are 
almost always costive, rarely loose. The dejections con- 
sist generally of dark brown fecal matter. In two of 
my cases the evacuations were of a tarry character, leading 
me to think I had the gastrorrhagic or enterorrhagic, united 
with the hsematuric form of this disease. But it was not 
settled by the microscope. AVhen htematemesis occurs as 
well as when the haemorrhage comes from the lower part of 
the intestinal canal, it is apt to be almost entirely blood. 
When it p.'oceeds from the stomach or upper part of the 
intestinal canal, and passes do\^^lward, it is altered " in tran- 
situ" by the gastric and intestinal secretions, and becomes 
of a black color, and offensive odor. 



HEMORRHAGIC MALARIAL FEVER. 



11 



I have purposely delayed until now to speak of the re- 
mission in this disease, for my observations do not accord 
with those of some of my Southern brethren. Some au- 
thors speak of the remission as always occurring, but I have 
never been able to recognize one except in the mildest forms 
of this disease. In these, the hsemorrhagic discharge ceases 
in the remission, and in Malarial Hsematuria the urine par- 
tially clears up, and all the other symptoms abate. In the 
severest forms remissions are not recognizable if they occur 
The bloody discharge continues at varying intervals, and 
there is no abatement in the other symptoms. Some authors, 
too, speak of the recurrence of the paroxysms only once in 
twenty-four hours. I never knew the interval to be so long- 
except in one extremely mild case. When there is a re- 
mission, the paroxysms always recur, according to my ob- 
servations, every ten or twelve hours, or oftener. It is cer- 
tainly reasonable to expect that they should do so. The 
quartan shows that malaria but feebly affects the organism, 
the tertian stronger, and quotidian stronger still. Then 
why, when the organism is overwhelmed by the prolonged 
action of the malarial poison, the nervous system depressed 
and the blood terribly impoverished, and scarce any resis- 
tive force left, should we not have the paroxysm recurring 
every ten or twelve hours, and in severe cases be unable to 
recognize any remission at all ? 

A favorable termination is preceded by cessation of the 
haemorrhage (and in Malarial Hiematuria the urine grad- 
ually clears up), nausea, and vomiting, restlessness and 
jactitation, the patient begins to sleep unaided by soporifices, 
and the appetite returns. An unfavorable termination is 
preceded by increased hseir orrhage, terrible nausea and 
vomiting, and jactitation, rapid exhaustion and collapse. 
Sometimes death occurs preceded by all the symptoms of 
ursemia, heart-clot, or, perhaps, cholestersemia. When the pa- 
tient dies from exhaustion, from loss of blood, the intellect 
is clear throughout his illness to almost the last moment of 



12 



HEMORRHAGIC MALARIAL FEVER. 



life. Not so, of course, when it occurs from ura^mic intoxi- 
cation. 

Causation. — Malaria is the exclusive cause of this affec- 
tion, which is intensified by excessive heat. Dr. Salisbury's 
cryptogamic theory has not been confirmed by others ; hence 
we are not warranted in accepting it. Oldham's views have 
not received favor enough from the profession to entitle them 
to consideration. 

Before the war the Southern States were in a high state 
of cultivation, and the lands thoroughly drained ; hence 
the malignant forms of malarial disease, as a general thing 
were not known, except in ver}' low, badly drained, swamp 
lands Within the past eight years, owing to so much land 
lying waste, defective drainage, and the general unsanitary 
condition of the country, the malarial poison has acted with 
an intense virulence, and caused the disease we are now con- 
sidering. 

Since the prevalence of this disease we scarce ever hear 
of the old algid pernicious fever. I will leave the solution 
of this to some one else. In population my county num- 
bers about 7,000. The first case since the war occurred in 
1866, since which time about fifty cases have occurred in 
the county. 

The first summer after the war, (1865), as well as the fol- 
lowing, a vast number of cases of malarial fever occurred, 
but only one case of hremorrhagic. It is remarkable that 
during the four years of the war, with very little land in 
cultivation for-three years of that time, our people were 
never so healthy before. In 1868 the town of Edenton was 
so thoroughly' drained, and put in such a sanitary condition 
generally, that its people enjoyed almost an immunity from 
malarial fevers ; and the few that did occur were of a very 
mild type. During that time, in the country around, we 
had some cases of heemorrhagic malarial fever. Edenton, 
since, has been sadly neglected, and this terrible form of 
malarial disease has been on the increase every year. Four- 



HEMORRHAGIC MALARIAL FEVER. 



13 



fifths of the fifty cases referred to, have occurred within the 
past four years, and nearly half of these in the town. 

It may not be out of place here to make a remark on the 
period of incubation of malarial fevers, for not only the laity, 
but many of our profession, hold erroneous views on this 
subject. The opinion exists in many minds that by spend- 
ing the months of June and July in a healthy locality, the 
following two or three months can be passed in malarial 
districts with entire exemption from miasmatic diseases. 
Abundant observation has convinced me that the period 
of incubation is frequently not so long as a month, though 
it may be many months and sometimes years. Drs. Flint 
and Maclean put it at from ten days to a month generally. 
When it is delayed for several years, it is, as Dr. Flint re- 
marks, " one of the most wonderful of the striking facts per- 
taining to these diseases." Dr. Maclean refers to an instance 
in which the period of incubation was less than twenty- 
four houis. 

Diagnosis. — Under this head I have but little to say. 
There is, I think, butone disease for which it may be mistaken 
— Yellow Fever. The jaundice, nausea, and vomiting, al- 
buminous urine, and black-vomit, together with impaired 
capillary circulation, make it somewhat resemble Yellow 
Fever; and the occurrence of these where Yellow Fever was 
prevailing might mislead one not well acquainted with the 
latter disease. As I have never seen a case of Yellow Fever, 
I must refer you for the differential diognosis to the writings 
of Southern authors, especially to the valuable contributions 
of Dr. Jones. This "undaunted soldier of truth," and one 
of the most reliable scientific investigators in the medical 
profession of our country, to whose kindness I am mainly 
indebted for my knowledge of the morbid anatomy of this 
disease, is now preparing a work embodying all his original 
investigations for the past twenty years. 

Prognosis. — All authors report the prognosis of this dis- 
ease as very unfavorable, the mortality ranging from 25 to 



HEMORRHAGIC MALARIAL FEVER. 



50 per cent., and sometimes higher. Dr. Michel, in the 
paper already referred to, calls it the most fatal disease he 
ever saw, and says that both he and Dr. T. C. Osborn, of 
Greensboro', Alabama, lost 50 per cent, of their cases. I 
don't think a patient with this disease could possibly recover 
vrithout treatment; and to treat them on antiphlogistic prin- 
ciples would not only surely cause death, but they would be 
hastened to the grave with almost telegraphic speed. The 
treatment greatly influences the mortality, the best chance, 
by far, of recovery being in a vigorous abortive and restora- 
tive treatment. The danger to life in all forms of malarial 
fevers is, of course, chiefly due, as Maclean says, to "the de- 
gree of malarial cachexia and the organic change to which 
it gives rise." In previously hard-worked, badly fed and 
broken down subjects the mortality is very high, as well as 
in those addicted to the excessive use of alcohol. The 
hiematuric attended with urseniic intoxication, and the gas. 
trorrhagic, are, perhaps, the most fatal forms; the non-ur^emic 
haimaturic, enterorrhagic, and epistaxic coming next. When 
two or more forms occur at same time of course the chances 
of recovery are greatly diminished When htemorrhage 
occurs from the womb, gums and fauces, it almost always 
does so in connection with some other form of the disease ; 
and shows an extreme cachexia and very low state of 
vitality. I should state, too, that the circumstances of 
the patient and good nursing have a certain influence on 
the mortality. If the patient cannot secure good nursing and 
good food the best medical treatment often fails. 

I have treated (all within the past seven years) eleven 
eases of this disease, ten of which recovered. My first case, 
the one that died, sank from pure exhaustion within an 
hour after I first saw her, her intellect being perfectly clear 
to almost the very close of life. This case occurred in a 
young girl just budding into womanhood, and w^as of the 
hsematuric form. She was " in articulo mortis " when I saw 
her, and remedial measures proved totally unavailing. In the 



H^EMORRHAGIC MALARIAL FEVER. 



15 



ten cases that recovered, eight were of the ha^maturic form, 
and the other two of the epistaxic. One of the latter was very 
mild, having a marked remission, almost intermission, of 
twenty-four hours. The other nine were very severe cases^ 
and had no remission whatever. In two of the hasmaturic 
slight symptons of uraemia occurred. 

The duration of the disease depends greatly on the treat- 
ment. Dr. Michel puts it at from four to twelve days. In 
my ten cases that recovered, they were all convalescence at 
periods varying from three to six days. In fifty cases that 
have occurred in this county within the past eight years, 
death or convalescence took place before the tenth day. It 
was exceptional for either to occur later than the fifth day. 

Modes of Death. — Death occurs in this disease in four 
ways, and in frequency in the order in which I shall name 
them : from exhaustion, from uraemic intoxication, from 
heart-clot, and, probably, from cholestera^mia. 

Prophylaxis. — This consists in those measures which 
will prevent the milder forms of malarial fever. Exposure 
to early morning and night air should be avoided, and it is 
well to wear thin flannel next to the skin. Linen clothes 
may be worn on very warm dry days, but early in the morn- 
ing and at night cassimere should be substituted. And as 
the cool frosty weather of Autumn approaches thick warm 
clothes should be worn. One whose system has been de- 
pressed, and blood impoverished, by severe heat and mala- 
ria, keenly feels the first cool weather, and particularly 
needs warm clothing and easily digestible and assimilable 
nutritious food. Indeed, all through the summer, the pa- 
tient must live on a lighter diet (unless he be a hard labo- 
rer) than in winter, for the digestive apparatus participates 
in the general debility of the economy. From three to five 
grains of quinine may be taken every morning for four or 
five days in -the week during the malarial season. Malaria 
has an affinity for thick foliage, hence the importance of 
few trees, and of keeping them well trimmed. Our late war 



16 



HEMORRHAGIC MALARIAL FEVER. 



demonstrated the fact that soldiers encamped in malarious 
localities, in an open field with few or no trees, were more 
exempt from malarial diseases than those encamped in 
woods. 

Persons sleeping in the upper story of houses enjoy, too, 
greater immunity' than those who sleep near the ground. 
But we cannot too strongly insist, when it can be done, that 
persons living in malarial districts should stay indoors un- 
til the air has received the purifying influence of the sun — 
Nature's disinfectant. 

Treatment. — A\'ere I to commence, under this head, by 
giving you a list of the remedies that have been highly re- 
commended for this disease. I would scarcely have paper 
enough here on which to write them. One physiHan extols, 
in addition to the mercurial and quinine treatment, nitrate 
of potash, water-melon seed tea, sweet spirits of nitre and 
buchu as diuretics, itc; another says his sheet anchor is 
hyposulphite of soda : in Florida "in addition to the mer- 
curial treatment, the physicians rely principally upon wood- 
ashes to control the bleeding:" and so I might go on enu- 
merating them tmtil I worried your patience. 

I will, before giving the treatment which, in my hands, 
has proved eminently successful, proceed, with due defer- 
ence to the opinions of those who differ from me, to criticise 
two methods of treatment which are practiced in the South- 
ern States. Just here let me beg that you will not forget, 
as I advance, that the reported mortality under these forms 
of treatment ranges from 25 to 50 per cent. I am surprised 
it is not more (it must be under the first I'll consider,) and 
the only reason I can see why it is not heightened is, that 
'•'the Almighty, in His infinite wisdom, has endowed the an- 
imal frame with an inherent ctirative power to thwart the 
machinations of misguided men." One of these, the so- 
called antiphlogistic, is, I am glad to say, practiced by a 
very small minority ; and yet I am ashamed for my pro- 
fession, that a single physician of ordinary intelligence can 



H^EMOERHAGIC MALARIAL FEVER. 



17 



be found who will pursue a course of treatment so at va- 
riance with the morbid anatomy and pathology of this dis- 
ease, as well as the recorded experience of a very large pro- 
portion of the ablest medical men in all countries. Indeed, 
I would not refer to this at all, did I not see from the med- 
ical journals that a few still practice it. In the Richmond 
and Louisville Med. Journal, for Feb'y, 1872, a physician in 
the South writing about this disease, says : "Many physi- 
cians in this section administer calomel and opium with a 
view to salivation, and place large blisters over the epigas- 
trium." The results of this treatment are not given. Of 
course not. After having given you the best views known 
of the pathological anatomy of this disease, and asking you 
to consider the blood state produced by salivation, I can ap" 
propriately close all I have to say about such treatment by 
a quotation from Dr. Maclean, which I confidently believe re- 
flects the views of every member present as it does of all, un- 
biased by a prejudice stronger than ignorance, who have 
devoted even a small portion of time to the clinical study 
of this disease. Says Dr. Mclean : "A practitioner of this 
school in India, in the present day would be an object of 
terror to all educated men within reach of his prescriptions. 
Beyond measure miserable is the spectacle of a man whose 
system, already saturated with malaria, is still further de- 
praved by the mercurial cachexy." For those who pursue 
such a treatment in such a disease — 

•'The only solace, if solace it be, 
Is that of a blind activity." 

I next come to those who pursue a socalled preparatory 
treatment before using quinine. These I think are far 
more numerous than the antiphlogistics and those who pur- 
sue the abortive and restorative treatment combined. In 
addition to the preparatory treatment, they also use strongly 
restorative measures. That I may do them no injustice, 
and to perfectly illustrate their practice, I will quote from 
a paper on this disease by a prominent southern physician, 
3 



18 



R^EMOBRHAGIC MALARIAL FEVER. 



published in a southern medical journal, at the request of 
the State Medical Society before which it was read. The 
views I am now about to criticise are held by some distin- 
guished physicians. I shall do so in the kindest spirit, and 
then see if I cannot point to a practice far better supported 
by pathology and clinical experience. I will now give you 
this author's treatment, but must ask you to bear in mind 
that he gives his mortality at fifty per cent. Says he : ''We 
must rely for success upon the administration of calomel 
and quinine. The former is used for its peculiar impression 
upon the liver and portal circulation, in addition to its pur- 
gative cjuality : and the latter not only for its tonic, but 
mainly for its antiperiodic property." He first gives twenty 
grains of calomel, and in six or eight hours, a dose of cas- 
tor oil : and as soon as successful purgation has been secur- 
ed, he gives 3 grs. ciuinine and \ gr. capsicum every hour 
until 21 grs. of the former and 3|- grs. of the latter are 
taken, being careful to give the entire amount at least two 
hours before the expected parox^'sm. He prefers vjaithig 
until the mercurial pjurge has finished its icork hefore attempt- 
ing to ward off the next febrile paroxysm " Should the chill 
recur,'" he further says, " with all its serious consequences," 
he again gives quinine, commencing before the intermission 
or remission occurs, in 3 gr. doses every two hours until 20 or 
more grains are taken or until the patient is thoroughly 
quininized. Others who pursue a similar treatment may 
sometimes give less or more calomel, and quinine in larger 
doses. Our author, previously to giving the treatment, 
says, " the bile is freely secreted, lodged in almost every tis- 
sue except the brain." Let us now carefully examine this 
treatment and see if it does not favor the high rate of mor- 
tality that attends it. And first, a few words only about 
mercur}' and its much vaunted cholagogue powers, for we 
have not now time to discuss this subject. Our author gives 
calomel '' for its peculiar impression upon the liver, " hav- 
ing previously admitted that the bile is freely secreted." 



H^miORRnAGIC MALARIAL FEVER 



19 



But some ^mll insist that the liver is torpid. Is the liver 
specially torpid, requiring a special remedy ? xlre not the 
brain, heart, stomach, lungs, feet, hands — yes, the whole in- 
dividual — more or less torpid ? Does he not manifest in all 
his functions lowered vitality? By the light that now 
guides us these questions must be answered affirmatively. 
Is mercury a cholagogue ? As before said, we have not 
time here to discuss this subject, but would simply ask, do 
the experiments of Scott and the Committee appointed by 
the British Medical Association to investigate this subject, 
reported through their Chairman Prof. Bennett, go for 
nothing in establishing this question ? Must such evidence 
be set aside for that of the physician who simply says " my 
experience " teaches me that mercury does act specifically on 
the liver, and when asked for his p)^'^^/^ almost invariably 
replies, " my senses cannot deceive me — my eyes see the bil- 
ious passages that follow the administration of this potent 
medicine." In diarrhoea following the ingestion of irrita- 
ting articles of food, would not his eyes also see the same 
• bilious stools ? In both cases, is not the bile hurried down 
oui per ana)n before time is allowed for its reabsorp- 
tion ? This view is held also by Murchison. In the Lon- 
don Med. Times and Gazette, of March 14th, 1874, he says 
" Mercury, podophyllin, &c., may sweep out the bile from 
the intestine before it is absorbed, but it does not follow that 
more has been secreted." In this sense only would I call 
mercur}^ a cholagogue. It drives out the bile already made 
but does not cause the liver to make more. It seems to us 
that the most scientific and reliable experimenters have 
shown ihdii food, and not mercury, is the natural and appro- 
priate stimulus to bile-flow. The pathologist to-day tells us 
that the blood of the patient suffering from mularial ca- 
chexia contains black pigment, w^hich is chiefly derived from 
the broken down red globules. Now if we reflect upon the 
important function of these little bodies in the animal 
economy, and the destructive influence exercised upon 



20 



HJEMORRHAGIC 3IALARIAL FEVER. 



them, as well as the other constituents of the blood, by 
mercury, the absence of proof of its cholagogue power, even 
if we admit special torpidity of the liver, ought we to use 
such an agent except as a jnirgative, this being the only ben- 
eficial action we lirioyj it to possess in such cases ? 

But here is something very strange and must contriVjute 
not a little to fatality in this disease. Our author, from 
whom we C[uoted a little while ago, and who may be taken 
as a good type of those who pursue the so-called preparato- 
ry treatment, first gives 20 grs. calomel, and in six or eight 
hours a dose of oil ; after the operation of which he gives 
quinine, preferring, as he says, to wait for the action of the 
medicine before giving the only remedy (quinine) upon which 
we can rely to cure the disease. Suppose the next paroxysm 
should carry off the patient, would he say the result was 
due to the symptoms he was combating, or to the influence 
of the toxic agent, the causa mail ? Much valuable time is 
also wasted in treating complications. 

Dr. Maclean, who has a right to speak on this subject, 
having had twenty-two years experience in the British ar^ny 
in India, condemns in unmeasured terms all except the 
abortive and restorative treatment of malarial fevers. And 
Dr. Flint, in his admirable work on Practice, strongly en 
forces the importance of the abortive treatment in malarial 
fevers, though he does not mention ever having seen a case 
of this disease. Surely, though, if the abortive treatment 
is applicable and in many cases urgently required, in the 
milder forms of malarial fevers, it must be ten times more 
so in this grave affection. 

Dr. Flint says in his treatment of intermittent fever, (and 
he has treated in the South a large amount of malarial 
fevers,) " it is always desirable to arrest the disease as speed- 
ily as possible. Its morbid effects are less in proportion as 
it is quickly arrested, and the liability to relapses is dimin- 
ished. There is no need of preparatory treatment. Aside 
from the delay in arresting the disease, the measures here- 



HEMORRHAGIC MALARIAL FEVER. 



21 



tofore employed to prepare the system for the sulphate* of 
quinine or other special remedies were injurious. These 
measures were mercurial cathartics, emetics, and sometimes 
bleeding. They are not indicated in the treatment of in- 
termittent fever. A consideration of no small importance, 
as enforcing an immediate employment of the abortive 
treatment, is the possibility of an intermittent fever, at first 
simple or ordinary, becoming, after several paroxysm, per- 
nicious." In treating of pernicious fever, he says : "In sea- 
sons when pernicious cases prevail, there is much risk of 
lives being sacrificed by the delay in arresting the disease, 
incident to the employment of the so-called preparatory 
measures of treatment." 

But I must now give you a short quotation bearing on 
these points by Dr. Maclean, who was well acquainted with 
the disease we are considering. Says he : Practitioners 
who relax in their efforts to stop the exacerbations, who 
pause in the use of quinine while they apply routine reme- 
dies to this or that symptom, will have little success in the 
treatment of the worst forms of Indian remittents. My ex- 
perience has satisfied me that such symptoms are most ef- 
fectually met hy the means which directly tend to counteract 
the poison which is Iceejnng u]) the excitement and disturbing 
the functions of the organs to which it is conveyed hy the cir- 
culation^'' He also says : " Practitioners whose choicest 
weapon against ' bilious ' remittents is calomel, are but too 
familiar with the dark brownish black evacuations of cadav- 
erous odor, the appearance of which too surely indicates 
that an unfavorable termination of the case is at hand." 

I will not much longer detain you, as it will take me 
only a few minutes to give you the treatment that has so 
well succeeded in my hands. I shall first treat of the 
hsematuric form. In this disease the doctor is called ver}^ 
early, either in the chill or soon after. Except measures to 
bring on reaction, the treatment is the same if the patient 
is seen after the chill. If called in the chill, see that the 



H^miORRHAGIC MALARIAL FEVER. 



patient is warml}^ covered, have hot bricks put to feet, 
spine, &c., give him hot stimulating drinks, whether he re- 
tains them or not, as the vomiting thus early will rarely do 
harm, but simply rid the stomach of undigested food or 
any offe^^iding matters that ma}' be in it, and will also tend 
to bring on reaction. Then at once give him (if an adult) 
from J to J gr. acetate of morphine hypodermically. If the 
bowels are costive, give the patient an enema soon after 
giving the morphine. In twenty minutes after giving the 
morphine, the stomach, which shortly before would not tol- 
erate simple water in small quantities, will now bear quin- 
ine and a moderate amount of liquid food (beef-essence, 
beef-tea, &c.,) and stimulants. At this time, then, and soon 
after giving the enema, if found necessary to give it, ad- 
minister to the patient by the stomach, in capsules or liquid 
form, ten grains of quinine, and in a very few minutes 
after double this quantity by enema. Should the patient 
not be able to retain it in either way (all of my cases did 
easilv) give it hypodermically, in proportinate doses, very 
p-ood formula for which mav be found in last edition of 
Flint's practice. 

Let these doses be repeated every hour until at least from 
fortv to sixty grains or more are taken. If this amount of 
quinine should break the fever, its discontinuance now 
would be sure, in all severe cases, to cause a return of the 
symptoms. Hence it is highly important to give every day, 
for three or four days, from forty to sixty grains. As it is 
impossible to tell exactly how much quinine to give, we had 
better give too much than not enough : and surely I would 
not advise so much if less would do. I have found the 
amount mentioned not too much for adults. But in from 
four to six hours the effects of the morphine will wear out. 
As soon as we perceive it is doing so ^ we must give another 
injection, and this must be kept up at these intervals for 
two or three days. This at once puts the patient in a sweat 
(the skin thus supplementing the work of the kidneys), and 



L.ofC 



H^EMORBHAGIC MALARIAL FEVER. 



28 



markedly relieves the distressing nausea and vomiting ; the 
exhausting restlessness and jactitation,, too, gradually giv- 
ing way to quiet and repose. The patient during all this 
time must have all the beef tea and chicken tea, oyster 
soup, tfec, he can possibly digest, as well as good brandy or 
whiskey, at intervals varying from one to three hours. One 
ounce of brandy or whiskey (except in old topers) every two 
hours will generally be enough. I have never given a pur- 
gative in this disease. I would do so if I could get its good 
without its bad effects ; but, except one, I have never s^een 
a case of this disease, so fearfully prostrating is it, in which 
I did not think purgation would tend greatly to bring about 
a fatal result. I generally give a mild purgative as conva- 
lesence begins. I treat all forms of malarial fever on the 
abortive plan. Iced champagne, and lemonade with claret 
wine in it, are very grateful drinks, and the patient may 
take ice and ice-water in small Cjuantities and at not too 
short intervals, sedulously guarding against overloading 
and oppressing the stomach. 

In regard to internal haemostatics, I scarcely know what 
to say, as I gave none to my patients. 

Some extol the mineral acids for this as well as other pur- 
poses in this disease, but they are already retained in excess 
in the blood. Ounce doses of lemon juice are recommended 
by others. But, perhaps, the best are Ergot and the prepar- 
ations of Iron. But, while on this subject, I must not omit 
to call your attention to a paper on the use of Ergot in the 
haemoptysis of phthisis, by Dr. Austie, in the May (1873) 
Number of the Practitioner. In this he thinks he has 
found Ergot of decided value. But let me give you a short 
quotation from this paper, asking you to bear in mind that 
his patients received at the time no other treatment. Says 
he : "There is probably no subject in practical medicine 
on which more divergent opinions are held than the C[ues- 
tion how far the so-called styptics, internally administered 
produce a real effect in checking haemorrhage. That the 



H^EMORRHA GIC MA LABIA L FE YER. 



action of the more commonly employed internal haemostat- 
ics, is, to the last degree, uncertain (even though in a mod- 
erate number of cases they may apparently act with great 
promptitude and effect), I think no one of large experience 
will deny, unless he has entered upon the inquiry with the 
determination to see none but successful results." We can- 
not easily tell the effects of a medicine without using it alone. 

We could not do this with hctmostatics in thib disease, 
however alarming the haemorrhage, without being sure our 
patients would all die. Add to this how difficult it is to get 
into these patients enough of the essentials to save them, and 
you have at once my reason for never having given them. 
If it be true, as asserted, that Ergot slows the heart's action 
without disturbing its rhythm, and contracts the arterioles, 
it may prove a good remedy. As I believe this to be its 
action, as Brown-Sequard's experiments tend to show, I shall 
try in my next cases hypodermic injections of Ergot. "While 
Dr. Dillard, of Chowan, does not think we have a true haem- 
orrhage in these cases, his experience leads him to think 
Ergot useful in controlling the bloody discharges. For a 
long time Ergot has been used as a hai^mostatic. 

Sometimes, though rarely, there is present a good deal of 
urinary irritation, which is best relieved by bicarbonate of 
potash. 

For a similar reason to the above I have not used diu- 
retics in this disease. Under ordinary circumstances they 
would be useful when the urine is scanty, but here it is next 
to impossible to get into our patient, by stomach, rectum 
and hypodermically more than enough of the essentials to 
save him. We must nev&r forget that these essentials are 
'luinine^ noarisJiinent and stimulants'^ and that upon these, 
with good nursing, our patient's safety depends ; and that 
icithout enough of thest. other remedial nteasures toould prove 
totally unavailing. 

Eubefacients and dry cups may be applied over the kid- 
neys and stomach. I would never blister, for the blistered 



H^EMOBRHAGIC MALARIAL FEVER 



25 



surface would probably prove another source of bEemor- 
rhage. Atomized Cologne thrown upon the patient's face 
and head with the hand-ball atomizer is very grateful and 
refreshing. Diarrhcea is best relieved by opiates — hypoder- 
mically or by enema. 

The warm bath some times proves very useful. 

For a month or more after convalesence begins, the pa- 
tient ought to take quinine, iron and strychnine. I gene- 
rally give, thrice daily, at regular intervals, to an adult, a 
pill containing one grain of dry sulphate of iron, two grains 
of quinine and 1-40 grain of strychnine. 

The patient, too, should live generously. Removal to a 
healthy climate is a very important part of the treatment. 

The treatment of the other forms must, of course, in the 
main be similar to this. In the epistaxic it may become ne- 
cessary to plug the posterior nares. In the gastrorrhagic and 
enterorrhagic forms of the disease the patient must be kept 
perfectly quiet, which cannot be done without an opiate. 
In the former as little as possible must be taken into the 
stomach. Perhaps here the persulphate of iron by stomach, 
and the hypodermic use of Ergot, would do well. Small 
quantities of ice or cold water may be taken. Ice may be 
applied externally over the stomach in bladders. The same 
principles of treatment are applicable to the interorrhagic 
form. In this, as well as the above, the bowels must be 
kept quiet, and medicine administered hypodermically and 
by the mouth. Food must be given by the mouth and cold. 

It would not be proper for me to close this address with- 
out having something more to say about the use of Opium 
in this disease. Xotwithstanding its prompt relief of nausea 
and vomiting, thereby securing sleep and enabling the pa- 
tient to take food and medicine b}^ the mouth, a very large 
class of medical men, whose opinions are entitled to great 
weight, insist that it strongly tends to produce uraemia. If 
this be so, surely we must give it not at all, or with great 
caution. But is this true ? We must remember that one 
4 



26 HEMORRHAGIC MALARIAL FEVER. 



of the modes of death is by ureemic intoxication, and that 
this frequently occurs in the practice of those who give no 
opium in this disease. We must, then, carefully avoid call- 
ing a post hoc a jprojyter hoc. 

The few cases I have treated could not establish this point, 
but they materially helf> to do it. In not one of them did 
uraemia occur ; but, in two, slight symptoms of it appeared 
before any opium had been given. These symptoms 
promptly yielded to this remedy. If opium can be shown 
to be a capital remedy, not only for slight symptoirs of 
uraemia, but for ursemic intoxication, surely we have a just 
right to think that it would not produce it. 

But w^hile many of the most eminent physicians in all 
countries have warned us against the use of opium when we 
even suspected that ursemia might occur, I am, happily, en- 
abled to give you the best possible evidence in support of its 
decided value in this disease, which . I hope will go far to 
dissipate the fears of those who are afraid of its use in Heem- 
orrhagic Malarial Fever. 

In a paper on Bright's disease, by Prof. Loomis, m the 
Medical Record^ of May loth, 1873, he asks the question : 
"What are the means we have for controlling the effects of 
urea upon the nervous system ?" And thus he answers it : 
"I believe that opium is, of all drugs, the best. If called to 
see a patient who has already had a convulsion, or is hav- 
ing symptoms of convulsions, I should not hesitate to throw 
into his arm 10, 15 or 20 drops of Magendie's Solution of 
Morphine by the use of the hypodermic syringe. It will 
not kill him; but upon the other hand, I have seen it many 
times produce a calm, quiet sleep, profuse perspiration, in- 
crease the flow of the urine, and within a few hours the pa- 
tient awake to consciousness as the result." Dr. Loomis 
frequently repeats these doses with decided benefit should 
symptoms of returning convulsions occur. In an article by 
the same author on acute uraemia in August 1st, (1873) No. 
of same journal, he thus speaks of Bright's disease, after hav- 



HJEMORRHAGIC MALABIAL FEVER. 



27 



ing tried in vain dry cups, diaphoretics, hydragogue ca- 
thartics, &c: "Death becoming imminent, I asked Dr. Met- 
calfe to see him with me. At Dr. Metcalfe's suggestion, and 
under his direction, I administered to him my first hypo- 
dermic injection of morphine to a patient with uraemia, ex- 
pecting to see its administration followed by a fatal coma. 
To my astonishment my patient soon after its administra- 
tion passed into a quiet sleep, from which he was easily 
aroused, during which he perspired freely. On the follow- 
ing day he reported himself as greatly relieved ; his urinary 
secretion was re-established, and he was able to take and re- 
tain large quantities of milk, For six weeks I administered 
daily to this patient from 20 to 30 drops of Magendie's So- 
lution of Morphine hypodermically, with J ounce infusion 
of digitalis twice a day. During this time, not only was he 
relieved of most of his distressing symptoms, but his im- 
provement w^as so decided that he was able to walk about 
his rooms and go out to ride. In about two months he 
went into the country, and I only heard from him occasion- 
ally. His dropsy entirely disappeared." This patient sub- 
sequently died of another disease. Dr. Loomis gives seve- 
ral cases in which this treatment was followed b}^ favorable 
results, but I must refer you to the journals containing his 
articles. 

In the 4th edition of his admirable work on Practice, page 
831, Dr. Flint remarks, touching this question : "At Belle- 
vue Hospital, opium has been given largely, and chiefly re- 
lied upon in the treatment of ursemic convulsions, by my 
associate, Prof. Alfred L. Loomis, who has been led by his 
experience to consider this plan of treatment eminently 
successful. There is reason to believe that, so far from 
opium having a poisonous action, it renders the nervous 
system more tolerant of the ursemic poison." These views 
were held by me and guided my practice before the publi- 
cation of Dr. Loomis's papers, and before he held similar 
ones, (1868.) But the following extract from a letter from 



28 



HJEMORRHAGIC MALARIAL FEVER. 



that great therapeutist, P.of. Metcalfe, of N. Y., shows that 
he long ago pursued this practice. A few months ago I 
wrote to him asking his views on this subject, after having 
freely given him mine in regard to the superiority, over all 
others, of the abortive and restorative treatment of Hsemor- 
rhagic Malarial Fever, and the use of opium. His reply 
was very gratifying to me. Says he : "Were I to write 
pages I could say no more than to express my cordial ap- 
proval of the therapeutics you have adopted. For many 
years I have known and taught that the old notion of in- 
compatability between uraemia and opium, especially when 
we could regulate the dose (as we can by hypodermic use), 
was a bugbear of tradition." 

Unfortunately, should uraemia or slight symptoms of it 
occur in the course of the affection we have been consider- 
ing, w^e cannot use some of the measures sometimes success- 
fully employed in this disease. We cannot use hydragogue 
cathartics. These would rapidly hasten death. We can 
use dry cups, hot air bath, and, perhaps, infusion of digita- 
lis ; but we must never crowd our patient's stomach. And 
polypharmacy in this disease is synonymous with fatality. 

While morphine promptly relieves the nausea and vomit- 
ing, and is, I think, a capital anti-ursemic remedy, we must 
not abuse the advantage it gives us. We may destroy its 
good effects upon the stomach, by loading this organ with 
too much food and nauseous drugs. Every thing must give 
way to those things upon wdiich our patient's safety de- 
pends, and the utmost caution and care are required in 
their administration. In uraemic intoxication, in addition 
to the hypodermic use of morphine and external measures, 
we are justified in giving digitalis. 

The treatment, gentlemen, which I have given you, and 
which has served me well, is, I think, sanctioned alike by 
pathology, clinical experience and common sense. To de- 
lay in administering our only hope of cure, and waste time 
so precious in vain attempts, by a so-called preparatory 



HEMORRHAGIC MALARIAL FEVER. 



29 



treatment, to rectify the " torpid " liver, purge away " vitia- 
ted secretions," check the h?einorrhage, &c., all symptoms 
only of the true dissase, is to witness a fatality that a more 
rational treatment would prevent. I trust that some of you 
at least will give this subject careful thought and study, and 
that in the not distant future you may be able to throw a 
flood of light upon points in its pathology and therapeusis 
which to us now are obscure and inpenetrable. We must 
not be too hasty in forming opinions in regard to the action 
and value of medicines. Let us study well physiology and 
pathology, and as our knowledge advances in these branch- 
es we will know more about the most difficult of all — ther- 
apeutics. In regard to the last, we must honestly say, "our 
knowledge is a little matter, our ignorance immense." We 
all should cherish this belief, and we will not then, as is too 
often done, by over drugging prevent our patients from get- 
ting well. Even now, in this comparatively enlightened 
age, polypharmacy is hurrying thousands to a premature 
grave. Who dares doubt this ? To do so would show an 
ignorance of what is going on in the world. Permit me to 
give you on this subject of therapeutics a short quotation 
from an address delivered a few years ago by Sir Thomas 
Watson before the Clinical Society of London. Says he : 
" Certainly the greatest gap in the science of medicine is to 
be found in its final and supreme stage — the stage of ther- 
apeutics. To me it has been a life-long wonder how vague- 
ly, how ignorantly, how rashly, drugs are often prescribed. 
We try this, and not succeeding, we try that, and baffled 
again, we try something else, and it is fortunate if w^e do no 
harm in these our tryings. Now this random and haphaz- 
ard practice, wherever and by whomsoever adopted, is both 
dangerous in itself and discreditable to medicine as a 
science." 

I could give you from others, the best authors in our pro- 
fession, views similar to the above. 

It is better for us to doubt, if by so doing we are led to 



so 



ILmiORRHA QIC MALARIA L FE VER. 



rational instead of blind belief. These views apply with 
striking force to my subject. In this, as well as other grave 
diseases, we had better be careful how we give remedies of 
doubtful value. For here what doesn't do good, often does 
much harm. And mild affections are frequently aggravat- 
ed by over-medication, and a neglect^ of the simplest hy- 
gienic laws. Imbued with these princi^^^ and always care- 
fully studying the natural history of disease, we will be more 
likely to learn the real value of remedial agents. Let us 
take fresh resolves to study faithfully our profession and 
love it. Then the chains of tradition will never bind us, 
and our progress, though it may be slow, will be sure. 

Let ns feel with Tyndall, that " an honest receptivity and 
a willingness to abandon all preconceived views, however 
cherished, when they conflict with the truth, is the first mark 
of a true philosopher;" and with Richardson, the English 
physiologist, that " if a single earthly object has to be 
served by our labor, and that be its design, assuredly the 
labor is damned forthwith." We will then be w^orthy dis- 
ciples of one of the noblest of professions, and honored guar- 
dians of our race, and the plaudits of grateful patrons will 
hail us as true friends and benefactors. 



LIBRARY OF CONGRESS 



021 623 840 



He 



LIBRPRY OF CONGRESS 



021 623 840 ^ 



Hollinger Corp. 
pH 8.5 



